Hipoglucemia de hyperinsulinemic precipitada por la prdida de peso.

"\"\\\"\\\\\\\"* Insulinoma revealed by voluntary weight loss.

\\\\\\\\n\\\\\\\\nDiscussion

\\\\\\\\n\\\\\\\\nCase Report

\\\\\\\\n\\\\\\\\nConclusion: Classically, insulinomas present with weight gain and
fasting hypoglycemia but may present with postprandial hypoglycemia and
weight loss. Voluntary weight loss, by lowering insulin resistance,
accelerates the time to clinical presentation of an asymptomatic
insulinoma.

\\\\\\\\n\\\\\\\\n Objective: To describe a case of hyperinsulinemic hypoglycemiaprecipitated by weight loss.\\\\\\\\nMethods: We present a detailed case report and results of a related
literature search on hyperinsulinemic hypoglycemia precipitated by
weight loss.

\\\\\\\\n\\\\\\\\nIn conclusion, we have described an unusual case of
hyperinsulinemic hypoglycemia due to an insulinoma, the effects of which
were precipitated by voluntary weight loss and lowering of insulin
resistance. Furthermore, the presentation was unusual in that the
hypoglycemia presented in the postprandial state (even though it was
reproduced during a supervised fast) and the diagnostic workup was
accomplished https://www.youtube.com/attribution_link?a=gcSRcM-UAvM&u=%2Fwatch%3Fv%3DgcSRcM-UAvM%26feature%3Dshare - green coffee bean max precio colombia - in the outpatient setting.

\\\\\\\\n\\\\\\\\n4. Jones TW, Porter P, Sherwin RS, et al. Decreased epinephrine
responses to hypoglycemia during sleep. New England Journal of Medicine 1998;23:1657-1662.

\\\\\\\\n\\\\\\\\nA contrasted abdominal CT scan was within normal limits; however,
an endoscopic ultrasound revealed a 12 X 10 mm hypoechoic mass in the
neck of the pancreas just above the portal vein confluence. Endoscopic
surgery was performed http://www.purevolume.com/listeners/mgiannam4/posts/4416598/Entrevista%3A+Jessica+Chastain+habla+de+su+gran+%22Tomar+refugio%22+la+nueva+pel%C3%ADcula+y+abofetear+a+Pimp+Michael+Shannon - http://www.purevolume.com/listeners/mgiannam4/posts/4416598/Entrevista%3A+Jessica+Chastain+habla+de+su+gran+%22Tomar+refugio%22+la+nueva+pel%C3%ADcula+y+abofetear+a+Pimp+Michael+Shannon - with successful enucleation of a benign
insulinoma. Postoperatively, the patient developed intestinal
obstruction from an internal herniation that was successfully managed.
The patient subsequently did well with both relief of hypoglycemic
symptoms and normalization of serum glucose. He was able to continue his
Weight Watchers program, losing an additional 9 pounds within the next
month.

\\\\\\\\n\\\\\\\\nA 56-year-old white male presented for evaluation of hypoglycemia.
In the preceding four months he had joined a local Weight Watchers
program and had lost 70 pounds. Two weeks before presentation, he
noticed episodes of confusion, disorientation, and diplopia occurring 3
to 4 hours after eating. There was no history of fasting or nocturnal
symptoms. During one of his symptomatic periods, he left work, drove
through three red lights and on arriving at home, drank a shot of
whiskey in an attempt to alleviate his symptoms. His wife found him in a
confused state and unable to operate the television remote control.
Since her mother was diabetic and was often hypoglycemic, she gave him
orange juice, and he promptly recovered. He subsequently noticed that
similar symptoms could be reversed by consuming sugar-containing
beverages or food.

\\\\\\\\n\\\\\\\\nReferences

\\\\\\\\n\\\\\\\\nConclusion

\\\\\\\\n\\\\\\\\nResults: The presence of an insulinoma was unveiled by voluntary
weight loss and reduction of insulin resistance. Hypoglycemia occurred
during the postprandial period and not at night. The diagnostic workup was accomplished without hospital admission.

\\\\\\\\n\\\\\\\\nInsulinomas typically present with fasting hypoglycemia,
neuroglycopenic symptoms, and inappropriate insulin secretion. In
response to these symptoms, patients often tend to increase their food
intake and gain weight. We report the case of a patient in whom an
insulinoma was diagnosed in the context of rapid weight loss and
postprandial, rather than fasting, hypoglycemia.

\\\\\\\\n\\\\\\\\nReprint requests to David S.H. Bell, MB, FACE, Faculty Office
Tower, Room 702, 510 South 20th Street, Birmingham, AL 35294. Email:
dshbell@uab.edu

\\\\\\\\n\\\\\\\\n**********

\\\\\\\\n\\\\\\\\nRELATED ARTICLE: Key Points

\\\\\\\\n\\\\\\\\n* Hyperinsulinemia can present with postprandial hypoglycemia.

\\\\\\\\n\\\\\\\\nAccepted January 14, 2005.

\\\\\\\\n\\\\\\\\n5. Bolli GB, De Feo P, De Cosmo S, et al. Demonstration of a dawn
phenomenon in normal human volunteers. Diabetes 1984;33:1150-1153.

\\\\\\\\n\\\\\\\\nKey Words: hyperinsulinemic hypoglycemia, insulinoma, outpatient
diagnosis of insulinoma, postprandial hypoglycemia, voluntary weight
loss

\\\\\\\\n\\\\\\\\n6. Simon C, Brandenberger G, Follenius M. Absence of the dawn
phenomenon in normal subjects. J Clin Endocrinol Metab 1988;67:203-20.

\\\\\\\\n\\\\\\\\n\\\\\\\\nA second unusual feature of this case is that this patient had nonocturnal or early morning hypoglycemia or precipitation of hypoglycemiawith exercise and presented with postprandial late-morning hypoglycemia.His symptoms would consistently occur 3 to 4 hours after ingestion offood. This was not true postprandial hypoglycemia, however, because whenfasting, the patient's hypoglycemic symptoms occurred at exactlythe same time of the day. Therefore, this was most likely a fastinghypoglycemia that was unaffected by a low-calorie breakfast. Wepostulate that he became hypoglycemic at this time due to lowering ofinsulin resistance. The \\\\\\\\\\\\\\\"dawn phenomenon\\\\\\\\\\\\\\\" describes the timeof day when insulin resistance, due to nocturnal growth hormone spikes,is at its highest, and in diabetic patients, increased basal insulin isrequired during this 4 to 5 hour period which ends 2 to 3 hours afterbreakfast. (2) Since calorie restriction increases growth hormonelevels, his low-calorie diet could have further impeded the developmentof hypoglycemia. (3) We also believe that nocturnal hypoglycemia maywell have been present and not recognized by the patient since evennondiabetic children sleep through nocturnal hypoglycemia. (4) Theexistence of a dawn phenomenon in nondiabetic individuals is still amatter of controversy. If present, it has been attributed to a transientfall in insulin sensitivity and an increase in insulin clearance. (5,6)\\\\\\\\nA third unusual feature of this case is that we managed to
completely work up the patient's hypoglycemia without admitting him
to the hospital. Usually fasting is started as an outpatient and if
hypoglycemia has not occurred by midafternoon on the first day of the
fast, the patient is admitted to the hospital so that fasting and
observation can continue. Therefore, under normal circumstances, the
fast would only be 8 to 10 hours old at this point, and only a third of
insulinoma-induced hypoglycemias would have occurred (7). In this case,
since the patient had no nocturnal events and was driven to the
outpatient facility, we felt comfortable starting the fast the evening
before and were therefore able to diagnose hyperinsulinemic hypoglycemia
after a sixteen hour fast in the outpatient setting. Furthermore, as the
anatomic diagnosis of the insulinoma was made utilizing endoscopic
ultrasound, the need for more invasive, inpatient testing, such as
celiac angiography, was not required.

\\\\\\\\n\\\\\\\\n7. Hirshberg B, Livi A, Bartlett DL, et al. Forty-eight hour fast:
the diagnostic test for insulinoma. JCEM 2000;85:3222-3226.

\\\\\\\\n\\\\\\\\nFrom the University of Alabama Medical School, Birmingham, AL; and
Family Practice, Madison, AL.

\\\\\\\\n\\\\\\\\nThis case is unusual in that the patient's hypoglycemia was
associated with weight loss. Usually hypoglycemia is associated with a
weight gain due to increased caloric intake stimulated by hypoglycemia.
We hypothesize that this patient's hypoglycemia occurred several
years earlier than normal as a result of the patient's voluntary
weight loss. By reducing his BMI from 45.5 to 36.7, we estimate that
this 19% weight loss resulted in a 31% decrease in insulin resistance.
(1) We also postulate that the patient's weight gain (30 pounds in
the year before starting his diet) was due to hyperinsulinemia. We
believe that this weight gain would have continued with increasing
insulin resistance until the insulinoma grew to a size where enough
insulin was produced to overcome the patient's insulin resistance,
and at this time, hypoglycemia would have occurred. In other words, the
weight reduction diet short-circuited the normal series of events
(hyperinsulinemia, hyperphagia, weight gain, increasing insulin
resistance, tumor growth, and then hypoglycemia) and led to removal of
the insulinoma at an earlier stage of growth.

\\\\\\\\n\\\\\\\\n1. Goodpaster BH, Kelley DE, Wing RR, et al. Effects of weight loss
on regional fat distribution and insulin sensitivity in obesity.
Diabetes 1999;48:839-847.

\\\\\\\\n\\\\\\\\nMaria S. Prelipcean, MD, Patrick J. O'Neil, MB, and David S.
H. Bell, MB

\\\\\\\\n\\\\\\\\n2. Campbell PJ, Bolig GB, Cryer PE, et al. Pathogenesis of the dawn
phenomenon in patients with insulin-dependent diabetes mellitus.
Accelerated glucose production and impaired glucose utilization due to
nocturnal surges in growth hormone secretion. N Engl J Med
1985;312:1473-1479.

\\\\\\\\n\\\\\\\\n\\\\\\\\nThe patient's past medical history was remarkable only for amild depression which was being treated with paroxetine hydrochloride.The only significant family history was type 2 diabetes mellitus in hisfather. The patient did not smoke and drank alcohol only occasionally.Examination revealed a 6'3\\\\\\\\\\\\\\\", 292 pound gentleman with a BMI of36.7. The remainder of the examination was normal.\\\\\\\\nA 3-hour postprandial plasma glucose of 42 mg\\\\\\\\\\\\\\\/dL was documented in
his primary care physician's office, and on his first endocrinology
visit, a fasting plasma glucose was 86 mg\\\\\\\\\\\\\\\/dL. Glycosylated hemoglobin
was 4.9%. An outpatient fast was initiated. Since he had no fasting or
nocturnal symptoms and his wife agreed to drive him to the clinic, the
fast was started at 6:00 PM the previous evening. After 16 hours (10:00
AM) the patient became symptomatic with a serum glucose level of 36
mg\\\\\\\\\\\\\\\/dL and an insulin level of 6.5 mcU\\\\\\\\\\\\\\\/mL. Therefore, the requirements
for Whipple triad was satisfied http://timesofindia.indiatimes.com/topic/Weight-Loss - http://timesofindia.indiatimes.com/topic/Weight-Loss - since his symptoms and serum glucose
quickly responded to oral glucose administration. Glucagon was not
administered at the end of the fast. The inappropriately elevated
insulin level > 6 U\\\\\\\\\\\\\\\/mL in the setting of a serum glucose
concentration lower then 45 mg\\\\\\\\\\\\\\\/dL indicated hyperinsulinemic
hypoglycemia and further workup was performed. Fasting C-peptide was 2.9
ng\\\\\\\\\\\\\\\/mL and cortisol and growth hormone responses to hypoglycemic
stimulation were adequate. A urine screen for sulfonylureas was negative
and at the time of hypoglycemia, ketones were absent from both the serum
and urine. Thyroid, liver, and renal function tests and a serum calcium
level were normal.

\\\\\\\\n\\\\\\\\n* Insulinoma can be diagnosed in an outpatient setting.

\\\\\\\\n\\\\\\\\n\\\\\\\\n3. Douyon L, Schteingart DE. Effect of obesity and starvation on
thyroid hormone, growth hormone, and cortisol secretion. Endocrinol
Metab Clin North Am 2002;31:173-89.

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